4358_001//,C. JS9"
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: �~.edmonclswa.gov.
PLEASE NOTE.- Intake appointments are required for New Single Family
Residences, Large Adclitions, ADU's, New Commercial, and Major Tenant
improvement application submittals. if plans are prepared by a profession-
al. electronic files are requested in addition to the hard copies. Please bring
el'ectronlc files on a flash drive or coordinate Tor eiecti uniL Zl'as 15— -
--fii A-2C-T71-11122111 fn SEIIPMUle On Intake OPPOIntnilentl
JOB SITE INFORMATIONILOCATION: l(Where the work is taking place)
& V.-
Job Site Address:
Parcel:
Lot /Unit/Suite #: — Subdivision:
PROPERTY OWNER:
Name, �fiji�mjac, 6712ARIC-4<
11).. P�a(002
Mailing Address: F
City/State/Zip:
Phone #: Ac 6-j:
Email:
OWNER INSTALLATION: *if yes, read and sign*
Will work be performed by the property owner? Yes 0 No
I own, reside in, or will reside in the completed structure. This
installation is being made on property that I own which Is not
Intended for sale, lease, rent, or exchange according to RCW
18.27.090.
Owner Signature:-,
APPLICANT / CONTACT INFORM�TION:
Name of Applicant:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
GENERAL CONTRACTOR: (if dilferent from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone#: —
E-mail:
STATE USI #:
CITY OF EDMONDS BUSINESS LICENSE 11:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Permit #:
=d7 01
0 Accessory Structure/
Detached Garage_
0 Demolition
[3 New Single Family / Duplex
0 Fire Sprinkler
0 New Commercial/ Mixed Use
0 Signs
XAddition
0 Mechanical
0 Plumbing
Q Remodel
0 Re -Roof
0 Tank
0 Tenant improvement 1 0 other
Fiernode, permit fees are based on:
The value of the work performed. Indicate the value (rounded to
the nearest dollar) of all equipment. materials, labor, overhead,
and the profit for the work indicated on this application.
valuation:
Basement sq ft:
ist Floor, sq ft:
2nd Floor, sqft:
Garage/Carport:, sq ft:
RnisheE Unfinished 13
Deck/Covered Porch/P8tI0: Leo --A
other sq ft:
C'V M17 V E-
I certify that the information I have provided on this form/application Is true,
correct and complete, and that I am the property owner or duly authorized
agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: A _S
'7_7
Signature: z;;; Date Z&6:9V_
F
GENERAL COMMERCIAL DATA
occupancy Group(s): occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes 13 NoO
WA STATE ENERGY CODE: if your project affects the building envelope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms. —
DEFERRED SUBMITTALS: All commercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
TI /CHANGE OF USE/ NEW BLDG: include TRAFFIC IMPACT worksheet
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
BTUs Gas / Elec / other City
A/C Unit /Compressor
Air Handier /VAV
Boller
Dryer Duct
ExhaustFans eLJ�Kgl C'
Fireplace
Furnace
HeatpumpUnit M191
Hydronic Heating
Roof Top Unit (Provide eleva-
tions If a Commercial Bldg)
eplAoc'- 741
Other: =0�19_to_ ILL=
PLUMBING FIXTURF COUNTS (New, RLIocated or re -piped)
MY My
Clothes Washer Tub/ Showers
Dishwasher Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain Pressure Reduction/ Regulator Valve
Floor Drain/Sink Refrigerator Water Supply
Hose Bibs Water Heater - Tankless? Y or N
Hydronic Heat Water Service Line
Sinks other:
Toilet other:
BTUs QW BTUs OtY
A/C Unit Outdoor BBQ / Fire pit
Boller Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert H Other:
I I I other:
Furnace I I I
Qt
Carbon Dioxide Nitrous Oxide
Helium Oxygen
Medical Air Other:
Medical - Surgical Vacuum Other -
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? Y / N PSCAA Case #:
Critical Areas Determination:
Study Required 0 Conditional Waiver 0 Waiver 0
rill in Place 11 rill Material:
Removal Size of Tank (Gallons)
Critical Areas Determination:
Study Required 13 Conditional Waiver 0 Waiver 0
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes 0 No 0
APPuCATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications, 2 years.
LICENSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
current CItY of Edmonds Business License.